Impact of Referring High-Risk Patients to Intensive Outpatient Primary Care Services: A Propensity Score–Matched Analysis

Background

Many healthcare systems have implemented intensive outpatient primary care programs with the hopes of reducing healthcare costs.

Objective

The Veterans Health Administration (VHA) piloted primary care intensive management (PIM) for patients at high risk for hospitalization or death, or “high-risk.” We evaluated whether a referral model would decrease high-risk patient costs.

Design

Retrospective cohort study using a quasi-experimental design comparing 456 high-risk patients referred to PIM from October 2017 to September 2018 to 415 high-risk patients matched on propensity score.

Participants

Veterans in the top 10th percentile of risk for 90-day hospitalization or death and recent hospitalization or emergency department (ED) visit.

Intervention

PIM consisted of interdisciplinary teams that performed comprehensive assessments, intensive case management, and care coordination services.

Main Outcomes and Measures

Change in VHA and non-VHA outpatient utilization, inpatient admissions, and costs 12 months pre- and post-index date.

Key Results

Of the 456 patients referred to PIM, 301 (66%) enrolled. High-risk patients referred to PIM had a marginal reduction in ED visits (− 0.7; [95% CI − 1.50 to 0.08]; p = 0.08) compared to propensity-matched high-risk patients; overall outpatient costs were similar. High-risk patients referred to PIM had similar number of medical/surgical hospitalizations (− 0.2; [95% CI, − 0.6 to 0.16]; p = 0.2), significant increases in length of stay (6.36; [CI, − 0.01 to 12.72]; p = 0.05), and higher inpatient costs ($22,628, [CI, $3587 to $41,669]; p = 0.02) than those not referred to PIM.

Conclusions and Relevance

VHA intensive outpatient primary care was associated with higher costs. Referral to intensive case management programs targets the most complex patients and may lead to increased utilization and costs, particularly in an integrated healthcare setting with robust patient-centered medical homes.